Patient Consultation Overview & Action Plan

Kennedy Lodato is here to help you move, feel, and live better. Fill out the quick form below

PERSONAL DETAILS

Your name

Email address

Phone number

Mobile number

Relationship Status

Birth Year & Age

Address

Medical Diagnosis

Prescription Medications

Supplements

Bowel Movements - Score your Stool - For guidance, please review the Bristol Stool Chart at the bottom of this page.

Type 1 – Separate hard lumps Type 2 – Sausage-shaped but lumpy Type 3 – Sausage with cracks on surface Type 4 – Smooth, soft sausage or snake Type 5 – Soft blobs with clear edges Type 6 – Mushy, fluffy pieces Type 7 – Watery, no solid pieces

How much water do you typically drink per day?

What type of water do you primarily drink?

Score Your Urine - Select the option that best matches your usual urine color

1 – Over Hydrated - Clear / Transparent 2 – Good - Very Pale Yellow 3 – Fair - Light Yellow 4 – Light Dehydrated - Yellow 5 – Dehydrated - Amber / Honey Colored 6 – Very Dehydrated - Brownish / Dark Amber 7 – Severe Dehydrated - Cloudy / Unusual Color

How is the flow of your Urine?

1 - Slow 2 - Appears normal

Sleep

Sleep Pattern

Acid Reflux

How would you describe your usual body temperature?

1 - Hot 2 - Normal 3 - Cold

How would you describe the temperature of your hands and feet?

1 - Hot 2 - Normal 3 - Cold

Have you noticed any changes in your hair?

Have you noticed any changes in your fingernails or toenails?

Dental

Urinary Tract Infections

Alcohol Consumption

Women - Menstrual Cycle

Birth Control

Women - Fibroids

Digestion

Mouth

Skin

Scalp

Chickenpox

C-Section baby

Yes No

Headaches/Migraines:

Joint Pain:

Anxiety/Depression:

Immunity:

Eyes:

Emotional Well-Being:

Appetite:

Antibiotic Use:

Coughing & Mucus:

Sweating:

Breathing:

Additional History/ Notes

I have read Why Work With Kennedy? and Professional Guidance and Moving Forward .

Yes No

Once you submit your request, we’ll reach out within one business day to confirm the appointment details and ensure the best possible match for your needs.

Trusted by 1000+ patients

Bristol Stool Chart (Bowel Movements - Score your Stool Reference Image)

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